Confidential Litigant Information Sheet (R. 5:4-2(G)) - New Jersey Judiciary
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1New Jersey Judiciary
Confidential Litigant Information Sheet (R. 5:4-2(g))
To assure accuracy of court records - To be filled out by Plaintiff or Defendant or Attorney
Collection of the following information is pursuant to N.J.S.A. 2A:17-56.60 and R 5:7-4.
Confidentiality of this information must be maintained.
Please complete the entire form, leaving no blank spaces. If something does not apply to you, enter “N/A”. This form is confidential
and will not be shared with the other party.
Docket Number:
CS Number:
Do you have an active Domestic Violence Order with the other party in this case?
Yes No
Plaintiff
Defendant
Name (last, first, middle initial)
Name (last, first, middle initial)
Social Security Number
Date of Birth
Place of Birth
Social Security Number
Date of Birth
Place of Birth
Address: Street
Address: Street
City
State
Zip
City
State
Zip
Plaintiff Telephone Number
Employer Telephone Number
Defendant Telephone Number
Employer Telephone Number
Employer Name (or other income source)
Employer Name (or other income source)
Employer Address: Street
Employer Address: Street
City
State
Zip
City
State
Zip
Professional, Occupational, Recreational Licenses
Professional, Occupational, Recreational Licenses
(include types and license numbers)
(include types and license numbers)
Driver's License Number
State of Issuance
Driver's License Number
State of Issuance
Sex
Race/Ethnicity
Height
Weight
Eyes
Hair
Sex
Race/Ethnicity
Height
Weight
Eyes
Hair
Male
Female
Auto: License Plate State
Make
Model
Year
Auto: License Plate
State
Make
Model
Year
Attorney Name
Attorney Name
Attorney Address: Street
Attorney Address: Street
1288 Rt. 73 South, Suite 301
City
State
Zip
City
State
Zip
Mt. Laurel
NJ
08054
Children Information
Social Security
Name (last, first, middle initial)
Date of Birth
Race
Sex
Place of Birth
Number
Health Coverage for Children - available through parent filling out this form (
Plaintiff /
Defendant)
Health Care Provider
Policy #
Group #
Health Care Provider
Policy #
Group #
Health Care Provider
Policy #
Group #
I certify that the foregoing statements made by me are true to the best of my knowledge. I am aware that if any of the foregoing statements made by
me are wilfully false, I am subject to punishment.
__________________________________
__________________________________
Date
Signature
Revised: 10/2012.
Easy Soft Effective September 1, 2013
Confidential Litigant Information Sheet
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Parent category: Legal